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Stem
A 33-year-old software engineer is brought to the emergency department by his wife. For the past 10 days he has slept 1 to 2 hours a night yet feels "full of energy". He has been talking rapidly and loudly, cannot be interrupted, jumps between topics, and has spent £15,000 on a business he believes will "change the world". He believes he has been chosen by God for a special mission. He is grandiose, irritable, and has no insight. He has a past history of two depressive episodes and his mother has bipolar disorder. He takes fluoxetine 20 mg daily, started 5 weeks ago by his GP for low mood. He drinks alcohol bingewise at weekends. Observations: afebrile, HR 96, BP 128/76, GCS 15, no focal neurology. Capillary glucose 5.6 mmol/L. Urine drug screen is negative.
Questions
a) What is the most likely diagnosis, and name two features in the stem that support it? (2 marks)
Diagnosis: acute manic episode, first episode of Bipolar I disorder (with mood-congruent psychotic features). Supporting features: (1) distinct period of elevated/grandiose mood with abnormally increased energy for over 1 week, with reduced need for sleep, pressured speech, flight of ideas and reckless overspending (DIGFAST); (2) a prior history of depressive episodes plus a family history of bipolar disorder; (3) the episode appears to have been precipitated by an SSRI (fluoxetine started 5 weeks ago) — antidepressant-induced affective switch.
b) Outline your immediate assessment and investigations. (2 marks)
Full psychiatric history (with collateral from his wife) and mental state examination; mandatory risk assessment (suicide, neglect, risk to others, financial/sexual exploitation — he has spent £15,000 and has no insight). Exclude an organic/substance cause — the negative drug screen and normal glucose/vitals/neurology are reassuring, but check U&E, LFT, FBC, TFT (exclude thyrotoxicosis), calcium, infection screen and obtain an ECG. Baseline bloods before starting a mood stabiliser (renal, thyroid, calcium, pregnancy test in women). A formal severity rating (Young Mania Rating Scale) documents baseline severity.
c) Describe your acute management, including legal and safety aspects. (3 marks)
The single most important pharmacological step is to STOP the antidepressant (fluoxetine) — antidepressants worsen mania. Then:
- Acute control — start an antipsychotic (e.g. haloperidol or olanzapine orally, or IM if agitated) for rapid control of agitation, psychosis and sleep; a benzodiazepine (lorazepam) may be added for short-term sedation.
- Start a mood stabiliser — lithium (start 400 to 800 mg/day, target a 12-hour trough level of 0.8 to 1.2 mmol/L in acute mania) or valproate.
- Safety/legal — he lacks insight and there is risk; if he refuses admission and there is risk to his health/safety/finances, admit under the Mental Health Act (Section 2 for assessment). Reduce stimulation, restrict access to credit cards/phone, and provide constant observation if high risk.
d) He is stabilised on lithium. Describe your long-term monitoring and the key complications of lithium. (3 marks)
Monitoring: lithium level (12-hour trough) 5 to 7 days after starting/dose change, then every 3 to 6 months; U&E/eGFR and TFTs every 6 months (TFTs every 3 months in the first year); calcium annually; weight/BMI, glucose and lipids. Counsel on avoiding NSAIDs, thiazides and ACE inhibitors, maintaining hydration, and reporting tremor/diarrhoea/ataxia (signs of toxicity). Add psychoeducation, interpersonal and social rhythm therapy (IPSRT) and CBT.
Complications of lithium:
- Toxicity (over 1.5 mmol/L) — coarse tremor, ataxia, dysarthria, nystagmus, seizures, coma; treat by stopping lithium, IV normal saline, and haemodialysis if severe.
- Long-term — nephrogenic diabetes insipidus (collecting-duct unresponsiveness to vasopressin), hypothyroidism/goitre, hyperparathyroidism/hypercalcaemia, weight gain, exacerbation of acne/psoriasis, benign leukocytosis.
- Teratogenicity — Ebstein anomaly (tricuspid valve); counsel and offer a fetal echocardiogram if pregnancy is planned.
- Note lithium's unique benefit — it reduces suicide by up to 60%, crucial given bipolar's high suicide rate.